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Suicide Attempts Decline After Cognitive Therapy

A series of cognitive therapy sessions may dramatically reduce the likelihood that previous suicide attempters will make a subsequent attempt.

After receiving a brief course of cognitive therapy, adults who had attempted suicide were half as likely to make another attempt compared with suicide attempters who did not receive the therapy.

In addition, those who received cognitive therapy had lower scores on measures of depression and hopelessness than did those who received only usual care in the community.

The findings appear in the August 3 Journal of the American Medical Association.

The report points out that one of the strongest risk factors for suicide is a previous attempt. Those who have attempted suicide are as much as 40 times as likely to commit suicide as those who haven't made a previous attempt.

Between October 1999 and September 2002, researchers from the University of Pennsylvania recruited 120 patients who wound up in the emergency room of the Hospital of the University of Pennsylvania in Philadelphia after attempting suicide.

The majority had overdosed on prescription, over-the-counter, or illicit drugs (58 percent). Others had stabbed, shot, or hung themselves.

Patients ranged in age from 18 to 66. Upon initial evaluation, 77 percent were diagnosed with a major depressive disorder and 68 percent with an alcohol or substance use disorder.

Researchers randomized 60 patients to receive 10 weekly or biweekly sessions of cognitive therapy. The therapeutic sessions were specifically designed to prevent suicide attempts. The other group did not receive the cognitive therapy.

Participants in both groups received "usual care" from clinicians in the community, which included, for example, substance abuse services, medication, and other types of psychotherapy.

There were no significant differences in the number of patients receiving psychotropic medications overall, the authors noted.

According to Gregory Brown, Ph.D., a research associate professor of psychology in the University of Pennsylvania's Department of Psychiatry and the primary investigator on the study, the therapy sought to help patients better cope with feelings of hopelessness and urges related to, for example, the use of alcohol or other drugs.

The Ph.D.-level therapists conducting the sessions also helped those experiencing interpersonal problems, he told Psychiatric News, by teaching them conflict-resolution skills and helping them to be more assertive in their interactions with others.

For patients who thought of themselves as "failures," Brown added, therapists worked on helping patients improve their self-esteem.

Patients in the cognitive-therapy group had to complete a relapse-prevention task successfully before ending therapy. Brown described the task as a "dress rehearsal for a suicidal crisis" in which patients were asked to review the chain of thoughts and feelings that led them to a previous suicide attempt and discussed how they would cope with these thoughts and feelings with the new coping strategies acquired during therapy.

Brown and his colleagues, including Aaron Beck, M.D., a psychiatrist at the University of Pennsylvania who developed cognitive therapy in the early 1960s, assessed patients in both groups to determine whether they made a suicide attempt and to measure levels of hopelessness, depression, and suicidal ideation at one, three, six, 12, and 18 months after the initial evaluation.

They found that 13 patients in the cognitive-therapy group and 23 patients in the usual-care group made at least one subsequent suicide attempt. The researchers estimated that those who received cognitive therapy were about 50 percent less likely to attempt suicide than those who received usual care only.

In addition, patients who received cognitive therapy had lower depression severity scores on the Beck Depression Inventory at the six-, 12-, and 18-month assessment points and experienced statistically significantly less hopelessness at the six-month point as measured by the Beck Hopelessness scale.

Brown pointed out that there have been only a few randomized and controlled trials on suicide prevention among those who have attempted suicide and described his findings as a way to "build an evidence-based approach to suicide prevention in the community."

He is beginning to do just that. He and his colleagues have begun training addiction specialists in the Philadelphia area to use cognitive therapy with patients who have alcohol and substance use disorders with the aim of suicide prevention.

These patients, he said, "often fall between the cracks" since the health system makes it difficult for them to obtain treatment for both problems in the same place.

An abstract of "Cognitive Therapy for the Prevention of Suicide Attempts" is posted at <http://jama.ama-assn.org/cgi/content/abstract/294/5/563>.

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